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mid a rising toll of opioid overdoses, recommendations discouraging their use to treat pain seem to make sense. Yet the devil is in the details: how recommendations play out in real life can harm the very patients they purport to protect. A new proposal from the Centers for Medicare and Medicaid Services to enforce hard limits on opioid dosing is a dangerous case in point.

There’s no doubt that we needed to curtail the opioid supply. The decade of 2001-2011 saw a pattern of increasing prescriptions for these drugs, often without attention to risks of overdose or addiction. Some patients developed addictions to them; estimates from the Centers for Disease Control and Prevention range from 0.7 percent to 6 percent. Worse, opioid pills became ubiquitous in communities across the country, spread through sale, theft, and sharing with others, notably with young adults.

The prescribing tide has turned: Private and governmental data show that the number of prescriptions for opioids has been falling since 2012. Reassuringly, federal surveys show that misuse of pain relievers bottomed out in 2014-15.

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Nevertheless, the CDC produced a guideline in 2016 that recommended shorter durations for opioid prescriptions and the use of non-drug treatments for pain. It also suggested keeping opioid doses lower than the equivalent of 90 milligrams of morphine. As the guideline acknowledged, its recommendations reflected weak scientific evidence. Problematically, it was silent on how to care for patients already receiving doses higher than the 90 milligram threshold.

To its credit, the guideline endorsed treating patients as individuals, not numbers. A CDC official wrote to one patient that the guideline “is not a rule, regulation, or law. … It is not intended to take away physician discretion or decision-making.”

Unfortunately, these mitigating features were undermined by intemperate publicity that vilified opioids for pain. Opioids for pain “are just as addictive is heroin,” proclaimed CDC Director Dr. Tom Frieden. Such statements buttress a fantasy that the tragedy of opioid overdoses and deaths will be solved in doctors’ offices, primarily by upending the care of 5 to 8 million Americans who receive opioids for pain, even when most individuals with opioid addiction did not start as pain patients.

The progression of the guidelines from “voluntary” to “enforceable” has culminated in a draft policy from CMS. It would block all prescriptions above the CDC threshold of 90 milligrams unless complex bureaucratic barriers are surmounted. Many pharmacy plans are already enforcing this approach. Under that plan, many patients suffering with chronic pain would lose access to the medicines they are currently taking, all in the name of reversing a tide of death increasingly defined by non-prescribed opioids such as heroin and fentanyl.

The logic of doing this is untested. There have been no prospective clinical studies to show that discontinuing opioids for currently stable pain patients helps those patients or anyone else. While doing so could help some, it will destabilize others and likely promote the use of heroin or other drugs. In effect, pain patients currently taking opioids long-term have become involuntary participants in an experiment, with their lives at stake.

Turning the voluntary guidelines into strict policy is unfortunate for three reasons.

First, it reflects a myopic misunderstanding of addiction’s causes, one at odds with a landmark report issued by the US surgeon general in November 2016. While the supply of drugs matters, whether people develop addiction to opioids reflects diverse factors including age, biology, and whether their lives include opportunities for rewarding activities like work and family or lacks those opportunities. Restricting prescriptions through aggressive regulation invites the outcomes seen in Prohibition, 90 years ago. To be fair to Prohibition, cirrhosis deaths did decline. But echoing that era’s gangsters and moonshine, we now face a galloping criminal trade in drugs of greater potency and lethality. Overdoses have skyrocketed, mostly from heroin and illicit fentanyl. In a Massachusetts review of overdoses, just 8 percent of those who had overdosed had received opioid prescriptions in the prior month.

Second, we have alternatives to bureaucratic controls. These include promoting and paying for treatments that de-emphasize pills. Important work by the Department of Veterans Affairs shows how to identify patients with elevated risk for harm from opioids and how to mitigate the risks.

Third and most troubling is the increasingly inhumane treatment of patients with chronic pain. Fearing investigation or sanction, physicians caring for patients on long-term opioids face a dire choice: to involuntarily terminate prescriptions for patients who are otherwise stable, or to carry on as embattled, unprotected professionals, subject to bureaucratic muscle and public shaming from every direction.

In this context, we cannot be surprised by a flurry of reports, in the press, social media, and the medical literature describing pain patients entering acute withdrawal, losing function, committing suicide, or dying in jail. The CMS policy, if adopted, will accelerate this trend.

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Many of our colleagues in addiction medicine tell us they are alarmed by the widespread mistreatment of pain patients. We receive anecdotes every week from physicians and pharmacists, most of them expert in addictions, describing pain patients who have involuntarily lost access to their pain medications and as a result have been reduced from working to bedridden adults, or who have become suicidal.

This loss of access occurs several ways. A pharmacy benefit program may refuse to cover the prescription because it has already enacted the changes that CMS is proposing to make mandatory. A physician may feel threatened by employers or regulators, and believes his or her professional survival depends on reducing opioid doses — involuntarily and without the patient’s consent — to thresholds that the CDC itself described as voluntary and not mandatory. Or state regulators have imposed such burdensome requirements that no physician in a given region can sustain prescriptions for their patients. Such patients are then “orphaned,” compelled to seek treatment from other physicians across the country.

Given the expertise in addiction among these physicians, it should be particularly worrisome that they believe the present pill-control campaign has gone too far. And yet, the ethics are clear: It should never be acceptable for us to countenance the death of one patient in the avowed service of protecting others, even more so when the projected benefit is unproven.

Surgeon General Dr. Vivek Murthy made an underappreciated declaration in a recent interview with the New England Journal of Medicine. “We cannot allow the pendulum to swing to the other extreme here, where we deny people who need opioid medications those actual medications. … We are trying to find an appropriate middle ground,” he said.

As addiction professionals, we agree wholeheartedly.

Stefan G. Kertesz, MD, and Adam J. Gordon, MD, are physicians in both internal medicine and addiction medicine. Dr. Kertesz is an associate professor of preventive medicine at the University of Alabama at Birmingham School of Medicine; Dr. Gordon is a professor of medicine at the University of Pittsburgh School of Medicine and editor of the journal Substance Abuse. The views expressed here are their own and do not reflect positions held by their employers.

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  • I am now going through Fentanyl withdrawal because my insurance company will not pay for my prescription. This is NOT healthcare. I ask a couple things. Someone keep a list of those who died directly because of these new changes. Keep a record of the suicides. Show that chronic pain patient’s are being made to look like addicts. Do NOT let this go. Lastly, God forgive me. I had a quality of life for four years. Now, the government took that away. My life is destroyed.

  • I am amazed that heroin users receive massive doses of methadone with no repercussions because they CHOSE to stick a needle in their arm to get high. I have arachnoiditis which is an incredibly painful spinal cord disorder 75% of diagnosed patients commit suicide in the first 6 months of being diagnosed. There is no cure treatment or hope just pain and a lot of it. Enough that I will vomit or pass out and the FDA is worried I might overdose on the 150mg of morphine I use daily. If I chose illegal drugs I could have an unlimited supply of methadone but because I have morals and honesty I spend many many hopeless painful days wondering why this is the case.

  • I’ve been disabled since 1995 officially, though that doesn’t take account of the 3 year battle, basically a waiting game, hoping to prevent anyone from surviving long enough for a review. Which the review was short & it was obvious the judge who reviewed a cancer survivor, a dose of Interferon 52 times what’s used today. A 24 square cm area if my neck, back & right shoulder put together with 5 figure 8’s with a cauterizer, by a general surgeon, later forced out of the hospital he was based. His follow-up for an area that large of some stage 2, mostly stage 3 melanoma was to look for lumps & he’d cut them out. Pure craziness! I battled severe lower back pain, & neck pain from as early as the early 80’s. Turned down by the same State DR 4 times for further care or review after work injuries, a 45 mph rear end collision, the 2nd one since 1977. After my 5 year cancer followup every place I complained of severe pain & let me say that I have a pain tolerance. Living with 2 broken ribs for 2 1/2 years, had several kidney stones which didn’t stop me till I had a temp of 104.5. I’ve broken just about every bone possible on the right side of my body, & many times I had no choice but to work through the pain. Tests found no disc at L5 S-1 the cause of lower back & leg pain, that are the same as putting a Tens unit on 10 & leaving it, C5-C7 in my neck almost as bad, with in 98 50% of my right radicular nerve dead, I’m right handed by the way. Early onset of Osteoporosis & Osteoarthritis, Fibromyalgia, myofascial pain syndrome, trigger points all over my body, squired torsion dystonia, the closest diagnosis my neurologist could use to describe what the general ‘surgeon’ did to me. Plus the after effects of 6 self administered Interferon shots a week for a year. I was put on every antidepressant, which either did nothing, or that & side effects sexually. Nobody’s curing depression by giving that to a man. Sleep meds like Ambien kept me awake for 3 days.Lyrica made me a mad man. Coming off those antidepressants can’t be worse than anything. A histal hernia & a bleeding stomach prone to day long or longer hiccups, which begin to feel like a heavy weight punch. To now diaphragm spasms that mimick heart attacks, nitroglycerin was found to be the only thing that worked & Xanax once at home or up to 4 before the imaginary knifes removed from my chest & mid back. A divorce due to my ex’s sudden onset of alcoholism, after 35 years, the death of my closest sister followed, then the harshest blow of all the death of one of my 2 sons this March. I delayed increasing my meds to include long term pain meds, till I had no quality of life. At 400 mgs of Oxycontin I was far from relief of pain, but I refused to go any higher. At least 17 years I’ve remained on the same meds, to someone who doesn’t know I fought for a decade to find sleep, which makes pain much worse. I’ve had salivary stones, cancer treatment turned my teeth soft, I maxed out my dental for close to a decade, now I have no teeth to speak of. Live on a level of income that frw could survive, & so called experts want me back in worse pain. I can only & sadly wish on them half the pain I’ve dealt with, TMJ also, olong with migraines. When you add all that up, all they’ll be leaving me is taking my own life. Which God knows how hard I fought. My boys were 9 & 12 when I was diagnosed with cancer. No matter that I went from 5’10” 175 to as low as 120 pnds. I spent quality time with my son’s, fishing, golfing with a cart on executive courses, but I fought the pain to be a good father. My son’s health started to decline after MRSA ended up taking his kneecap & a heartless dipsh** Company insurance company, not for health rather the company took his career. I watched him one by one develop what I had, I knew what would help but absolute hell for a loving father. Now with the change, I’m glad it will only be me whose made even more crippled. I don’t at all look forward to the hell it appears is set before me. I got my part D plan, no Oxycodone (generic) at all. I have already been to bed far too much. I wish I could shake the hands of one of these do good errors & for 5 minutes they could feel my pain, which it sounds like till I pull the trigger will only get worse. Justice? I lock up my meds & have never thrown out a pill bottle. Nor have I ever abused anything, I come from a line of alcoholics which in less than a handful of times I knew if I drank I’d be. So I know I had to be careful. Now for what quality of life? I had little before. Their names should be linked with my death when the pain becomes far too much to endure. There are many more like me, who because of others I must suffer more? I’ve done that & then some.

  • I sent the CDC this article and asked that they read the comments. It’s important to show them that their regulations are pushing people to seek illegal drugs – which is exactly what they were trying to PREVENT.

  • I have had 7 surgeries from bladder cancer and partial intestines removed to gall bladder and tendon release. Have had physical therapy for 20 years or more which is fine but not long lasting.Finally I went to a pain clinic and was prescribed pain managing prescription, and nerve blocks and such and it change life for me.I get relief even though briefly during my day that I hadn’t had in a long time, but now they are taking the meds away and I’m back to the time most of the day oF dealing wit pain. It’s not helping anyone when they do this, I have never abused my meds but am being punished because I’m considered a addict. I,m 59 years Olds ,I knew what I was getting in to so it’s on me, and I would do it again just for the relief it brings even for a short time. I wish you all love and support and the hope that you find pain relief too.
    Rob

  • I looked for exercises to keep the shoulder at least as good as it is until I get to ortho, phys therapy or whatever is in store. Saw something I found interesting enough to share and it’s completely relevant since this is exactly what I just experienced: copied from an article written by Dr. David Ryan on site Bodybuilding.com (no I’m not anywhere near being a bodybuilder, just looking for possible exercises)

    When a doctor tells you to quit lifting and to get on NSAIDS (Non Steroidal Anti-Inflammatory Drugs), you should consider finding a new doctor. Consider that over 16,500 people die/year in the US from reactions from those simple over the counter drugs. (British Medical Journal, June, 1999.)

  • Thank you to the individuals who wrote this article. I write this as I lie on my couch, just getting home from a MedExpress clinic. They took xrays and determined that I have a separation of the a.c. joint in my shoulder. They will only refer me to an orthopedist,told me to keep taking the anti inflammatory and Tylenol,which I’ve taken so much of that I went to the urgent care clinic in hopes they would help relieve some of my pain. They wouldn’t even give me Tramadol, which wasn’t even classified as an opioid until relatively recently. It’s now Sunday so by the time I might possibly get any relief my liver and stomach lining will be shot, not to mention those medications are no longer effective. I am considering taking a trip downtown to buy off the street. I think it will be easier & since I’ve already been suffering w this for several weeks hoping it’s just an injury that needs to heal, I’ve exceeded my pain tolerance level.

    • I too have.taken so much ibuprofen that I had internal bleeding caused from it and nearly died. I now am on Rx/low opioid .What other choice do I have? This.ia so horrible

  • Thank you for sharing both sides of the discussion. I believe the patient is being forgotten and being unfairly singled out by the system

  • ive been taking 10 mg hydrocodone for years as prescribed to take 2 times a day and i have had neck and back sugery and i need them just to have the quality of life and im 66 and still do physical work and cant do it without the medication and they cut me down to 60 a month from 90 and i can deal with that but leave me the fk alone for you see commercials with a person getting pain meds from dentist and then a syringe and heroin next and thats bull crap for a person like that has a problem and it snot my fault and CVS is now only prescribing opoids once a week now

    • Bill i here you I am going through hell Been in pain since 1995 but never started on hydrocone until I had debilitated ovarian cysts that would burst in 97 but neer took again until debilitating back issue took over my life in 2000 Since that my spine has degenerated & have been diagnosed with fibromyalgia in 2006 (3 yrs after symtoms started been going on & off for trigger point injections, bck & neck blocks and that brings me to this summer when I deeloped a painful rash on my left ankle/foot and eye symptoms that are crazy (dry eye/glaucome, a deformed optic nerve Chest pain , body pain increased My feet and hands cracked and bleeding WTH & the Dr telling me as I sit there falling apart that I am oer some NYS guideline for opiods Is this really for people like us to care about . We need relief & the addicts are way over there on another page Please I wish they would learn how to separate the two groups correctly Let’s try again folks really hurting for yrs and took there meds as directed over here and over here / are the addicts Sighs I wish they would hurry up & diagnose my new auto immune disease so I coyld see straight again Good luck Bill Moran

    • You are so right, Mr. Moran. All of the supposed professionals; doctors and their staffs, nurses, pharmacists, etc. should also be required training to eliminate the judgmental, demeaning treatment and power trips this situation has precipitated. The U.S. government has created this atmosphere with no thought of the outcome. Only reaction, aggression, show of power. I haven’t heard one bit of evidence that there is any knowledge behind the tactics they claim are working. A colossal failure for all involved. Including addicts, for whom I have tremendous sympathy. It’s a far reaching, destructive, generational disease. And people are still dying. It’s a tragic f.u. to the so called protectors of our nation and it’s people

  • in answer to your question whether your doctor is messing with your prescriptions. No he is not. I beg my doctor to give me more I was in his office just crying and crying and I had to be wheelchair out of the office because I couldn’t even walk how can I watch me go through this?

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